Medicaid Policy
Medicaid Policy
No Previous Policy
An incomplete claim is an overpayment or understated liability calculation that cannot be completed because the member will not cooperate in efforts to obtain sufficient information. This includes non-cooperation with an investigation.
If current eligibility is in question and the member will not cooperate and you cannot obtain sufficient information (731, verification) to resolve the questions, then you cannot establish the member’s current eligibility.
Deny the application or close the case. Document the outstanding overpayment issue in the case file and follow the rules in sections 811 and 827.
If the individual reapplies for medical assistance and the individual will not cooperate by providing sufficient information to resolve questions about current eligibility, then you cannot establish the individual’s eligibility. Deny the application.
If current eligibility is not in question and the overpayment or understated liability questions are about past months, you cannot deny, close, hold, reduce or change current Medicaid benefits. You may attempt to obtain the evidence (731) you need to resolve the questions. You must follow the rules in sections 105, 107, 111, and 115 to protect the member’s rights.